Spotlight: Treating Comorbid Chronic Pain and Substance Use Disorders

September 2012

Chronic pain and substance use disorders (SUDs) frequently co-occur in the general population and among Veterans who use the VA healthcare system. ¹ For each of these conditions, the presence of the other condition complicates treatment decision-making. Moreover, Veterans with co-occurring pain and SUDs tend to have worse outcomes than those with only one of these conditions.^2,3 The use of prescription opioids for the treatment of chronic pain has increased substantially over the past decade, and the risks of negative consequences of opioid use also have increased in individuals with SUDs. For example, recent research findings indicate that Veterans who receive VA healthcare are at elevated risk for opioid overdose relative to the general US population,⁴ and that Veterans with a substance use disorder are at significantly greater risk for overdose compared to other VHA patients. ⁵

During 2011, VA/HSR&D's Substance Use Disorders Quality Enhancement Research Initiative (SUD-QUERI) developed a special workgroup focused on the overlap between pain, SUDs, and medication misuse. The Pain and Pain Medication Misuse workgroup is devoted to studying ways to improve the treatment and quality of life of Veterans with both pain and SUDs. Overall, the goals of the workgroup are to:

• Identify ways to reduce substance use in those with both pain and SUDs;

• Develop ways to reduce pain and improve physical- and mental health-related functioning in those with pain and SUDs;
• Increase access to specialty care for both pain and SUDs in Veterans with these co-occurring disorders;
• Decrease the misuse of opioids prescribed for pain care among those with and without SUDs; and
• Identify strategies to reduce the likelihood of opioid-related adverse outcomes (i.e., falls, emergency room visits, and fatal and non-fatal overdoses) for Veterans with and without SUDs.

Currently, SUD-QUERI's Pain and Pain Medication Misuse workgroup supports three ongoing projects that are focused on:

• Comorbidity of pain and specific SUDs,
• Risk factors for overdose among Veterans with pain and SUDs, and
• Strategies for ameliorating low-quality opioid prescribing by VHA providers.

As results of the ongoing research become available, investigators who participate in SUD-QUERI's Pain and Pain Medication Misuse workgroup plan to collaborate with their strategic partners to develop larger projects to encourage greater implementation of evidence-based practices and decreased utilization of potentially-risky treatment in those with pain and SUDs. SUD-QUERI's Pain and Pain Medication Misuse workgroup is led by Dr. Mark Ilgen, in collaboration with researchers and policymakers from throughout VA, as well as within VA's Central Office.

For more information, please contact Mark Ilgen, Ph.D. at Mark.Ilgen@va.gov.

References

1. Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011;152(3):488-497.
2. Larson MJ, Paasche-Orlow M, Cheng DM, et al. Persistent pain is associated with substance use after detoxification: a prospective cohort analysis. Addiction. May 2007;102:752-760.
3. Morasco BJ, Corson K, Turk DC, and Dobscha SK. Association Between Substance Use Disorder Status and Pain-Related Function Following 12 Months of Treatment in Primary Care Patients With Musculoskeletal Pain. The Journal of Pain. 2011;12(3):352-359.
4. Bohnert AB, Ilgen MA, Galea S, et al. Accidental Poisoning Mortality Among Patients in the Department of Veterans Affairs Health System. Medical Care. 2011;49(4):393-396.
5. Bohnert AB, Ilgen MA, Ignacio RV, et al. Risk of Death From Accidental Overdose Associated With Psychiatric and Substance Use Disorders. The American Journal of Psychiatry. 2012;196(1):64-70.